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<br /> City of Orono
<br /> Building Permit Application
<br /> for New Structures or Additions
<br /> Mailing Address: Permit number. GLH(�• ^� • ;.
<br /> QA, PO Box 66 '
<br /> � `w0 Crystal Bay, MN 55323-0066 Date received: l -- � -�C,D
<br /> Street Address:� _ ___ Received by: _ ��� / ���
<br /> -- �- _ --
<br /> �' � 2750 Kelle Parkwa E£ '' �� 1
<br /> ti�, � y y C� � :' Plan review fee: �--� . � '
<br /> c.` Orono, MN 55356 �
<br /> `�kfSHOQ'� Main: 952-249-4600 -�'-���..`.y....'�"t''°�.,, -_ , ��. �? ,
<br /> otal Fee: ,_f � � u; , . -- �
<br /> Fax: 952-249-4616 www.ci.orono.mn.us
<br /> This application form must be completed in full and all required information must be submitted.
<br /> Incomplete applications will be retumed. (Please print) �-f r � � ' I �
<br /> GENERAL INFORMATION: " � � �
<br /> Job Site Address: �� �,..,���� /���
<br /> Will this be a Parade of Homes, Remodelers Showcase Home or other Display Home? ❑ Yes ❑ No
<br /> If yes,a special event permit is required with Police Department and City Council approva160 days prior to the event. Shuttle bus service will be
<br /> required unless applicant demonstrates sufficient on-site parking is available. Non-permitted events will not be allowed.
<br /> CONTRACTOR/APPLICANT INFORMATION: ,
<br /> Name: R.�n I.�.,ti.Q�,,.�- 1��„,.,� S�,.,����+,sr�„�:..,,_ us_
<br /> State License# (�� �..�,��� Expiration ate: �31r/-�
<br /> Phone: (cell) ��Z_-�.,�_S_-Tc��g (office) �ySz-fd3[e-zcoc�
<br /> Mailing Address: � Ci : , ZIP: -
<br /> Contact Person: �,.., ��..,�,,, Y;��,! Applicant is: Contract / Homeowner (Circle One)
<br /> Email and/or Fax: ��,,., C�_��,�,e� ,,.��,�'�im ,�,,,,o sQ��,� .�,c��nn
<br /> PROPERTY OWNER INFORMATION:
<br /> Name: �,o1�,�ri- IN1,1\,�,,r
<br /> Phone (day): �gz..� �S_ ����
<br /> Address: (� gti,,;�^ �� City: Q��N,r-� ZIP: 'rJS:'�S I
<br /> Email and/or Fax ,�oN,�„-�-�„,,,�,,;lt�.r_.�..�nR.�%.cow�,
<br /> ARCHITECT/ENGINEER INFORMATION:
<br /> Name: 21�5 /��� 4�,, 1.���s �$�.�- 5�..1���
<br /> Phone(day): ��Z, p�,�p_cy�g
<br /> Address: � Cit :N ZIP: -rj
<br /> Email and/or Fax: r,���rc\-s e.,_c . L��
<br /> I �
<br /> PROJECT INFORMATION: Description of pro�ect: � i�"'� '` J �� � �� � '- � �
<br /> 1.Type of Project 2.Proposed Use 3.Structure Type 4.Sewage Disposal 8
<br /> Water Supply
<br /> ❑ New Construction �Single Family with ❑Accessory Bldg./Garage
<br /> �Addition attached garage ❑ Deck � Public Sewer
<br /> ❑Accessory Building ❑ Single Family with ❑Office/Commercial
<br /> ❑ Relocation . detached garage � Residence ❑ Private Sewer
<br /> �f Other: (specify) 'Qa h.�.�� ❑ Multiple Family/Condo ❑ Retaining Wall(s)
<br /> ❑ Public 4-feet or greater ❑ Public Water
<br /> **Any earth movement may require ❑Commercial ❑Storage
<br /> MCWD review 8�permits. ❑ Industrial ❑Warehouse �Private Well
<br /> Minnehaha Creek Watershed District(MCWD) ❑Other:(speCify) ❑Other(specify)
<br /> 15320 Minnetonka Blvd
<br /> Minnetonka,MN 55345
<br /> Phone: 952-471-0590
<br /> Fax: 952-471-0682
<br /> www.mi n nehahacreek.or
<br /> Estimated Construction Valuation (excluding land) $ -rj�Q.pbp
<br /> Packet Last Updated. August 2015
<br /> Page 21
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